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Maroti, Ljungar: Differences in alexithymia and emotional awareness in exhaustion syndrome and CFS

Self-reported alexithymia was measured with the Toronto Alexithymia Scale-20 (TAS-20) and emotional awareness with an observer-rated performance test, the Level of Emotional Awareness Scale (LEAS). Additionally, depression and anxiety were scored by the Hospital Anxiety and Depression Scale (HADS).

Results show that patients with ES expressed higher self-reported alexithymia in the TAS-20 compared to HC, but had similar emotional awareness capacity in the observer-rated performance test, the LEAS.

Patients with CFS expressed more difficulties in identifying emotions compared to HCs, and performed significantly worse in the LEAS-total and spent more time completing the LEAS as compared to HC.

Correlation and multiple regressions analyses revealed that depression and anxiety positively correlated with and explained part of the variances in alexithymia scores, while age and group explained the major part of the variance in LEAS.

Findings of this study indicate that emotional status is different in patients with ES and CFS with respect to both self-reported alexithymia and observer-rated emotional awareness.

Emotional parameters should be approached both in clinical investigation and psychotherapy for patients with ES and CFS.

I've read the full-text version now. I think they are trying to say that the effect of CBT could be increased by adding a couple of "psycho-educative sessions of emotional awareness training", since CFS patients have insufficient emotional awareness capacity and big difficulties in describing feelings...

Oh how I wish they would stop trying to mess with what's going on in my head and get on with what's going on in my body. I'm afraid my reaction to this is my emotions are none of their damn business. Looks like another good reason to steer well clear of CBT.

There are striking symptom similarities in ES and CFS, at least when the Fukuda criteria for CFS are applied [...] ES is, however, considered a stressrelated psychiatric disorder caused by long-term psychological stress that is often, but not exclusively, work related [...] ES is related to high work demands in conjunction with low levels of influence or control (Söderström, Jeding, Ekstedt, Perski & Akerstedt, 2012).

CFS, on the other hand, is considered an organic multi-systemic illness with unknown cause (Carruthers et al., 2003).

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There is no consensus on how best to treat either ES (Glise, Hadzibajramovic, Jonsdottii & Ahlborg, 2013) or CFS (van der Meer & Lloyd, 2012), but in both conditions Cognitive Behavioral Therapy (CBT) is the usual psychotherapeutic treatment approach.

Prognosis is very different for ES and CFS, where the latter have a particularly worse prognosis. [...]
In CFS, few adult patients recover. One study following 50 patients showed no symptom improvement after one year (Pheby, Lacerda, Nacul et al., 2011), and as few as 18.3% were recovered 6 months after receiving CBT (Flo & Chalder, 2014).

Alexithymia is conceptualized as a general impairment in the capacity of emotional information, relating to both verbal and non-verbal stimuli (Lane, Sechrest, Reidel, Weldon, Kaszniak & Schwartz, 1996), and leads to disturbances of affect regulation (Waller & Scheidt, 2006). Alexithymic individuals have difficulties identifying their own or others’ feelings (Lane & Schwartz, 1987; Sifenos, 1973).

In addition, alexithymic individuals show an externally-oriented thinking style and a scarcity of fantasy life (Taylor, Bagby & Parker, 1997).

It has been argued that alexithymic individuals are vulnerable to incorrectly attributing benign bodily sensations to physical disease (Kooiman, Bolk, Rooijmans & Trijsburg, 2004). Having alexithymic tendencies could make it difficult to differentiate feelings from bodily states such as tension, distress and fatigue (Waller & Scheidt, 2006).

Alexithymia has been conceptualized as a stable personality trait (Taylor et al., 1997) or as a defensive state reaction to a stressful situation such as, for example, a traumatic event, or a medical, or psychiatric illness (de Vente, Kamphuis & Emmelkamp, 2006).

The aim of this article was to compare ES and CFS with a healthy control group in relation to self-reported alexithymia and observer-rated emotional awareness.

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CFS patients were diagnosed according to the Canadian criteria (Carruthers et al., 2003), and patients with ES according to criteria specified by the Swedish National Board of Health and Welfare (Socialstyrelsen, 2003, 2010).

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All groups answered questionnaires by sending in their answers in a prepaid envelope.

Level of Emotional Awareness Scale (LEAS). The LEAS is an observer-rated measure of emotional awareness. The shortened 10-item version of the LEAS was used (LEAS-A). The test consists of vignettes that describe emotion-provoking interactions between two persons. Participants are asked to describe how they would feel as a protagonist of each scene and how “the other person” would feel.[...]

Self-reported alexithymia
In the self-report instrument TAS-20, patients with ES described more difficulties with identifying and describing feelings [... and] more difficulties describing feelings as compared to CFS [...]. CFS patients reported more difficulties in identifying feelings as compared to HCs

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Observer-rated emotional awareness
[...] CFS patients performed significantly worse on the LEAS-total, and spent a longer time completing the task as compared to HCs

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The use of self-reported instruments to capture either mental health problems or alexithymia has previously been questioned (Shedler, Mayman, Manis, 1993; Waller & Scheidt, 2006). The TAS-20 self-reported instrument requires the respondent be aware of their diminished capacity to identify feelings.

It has been argued that what can be reported is actually a respondent’s belief about their ability to be emotionally aware and not actual emotional awareness capacity (Lundh, Johnsson, Sundqvist & Olsson, 2002).

Rater-observed instruments such as the LEAS address this caveat and have, therefore, been recommended to be used simultaneously with the TAS-20 (Waller & Scheidt, 2006).

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The present study is in line with earlier research showing that CFS patients report less or no difference in self-reported alexithymia compared to other illnesses and diseases [...]

Moreover, the results of this study indicate that emotional awareness capacity might be hampered in CFS when a performance-based measure such as the LEAS is used (Oldershaw et al., 2011). The results therefore indicate that patients with CFS have a more realistic view of their emotional capabilities, since they reported more difficulties in identifying feelings in the TAS-20 and demonstrated a lower emotional awareness capacity in the LEAS compared to HCs.

In an fMRI study where the feeling of fatigue was provoked, patients with CFS showed an increased activation in areas of the brain that form part of a network that has been associated with inhibitory processes and emotional regulation (Caseras, Mataix-Cols, Rimes et al., 2008). The results were interpreted as meaning that patients with CFS tend to over-regulate or suppress their emotional responses, which, if true, could contribute to lower scores in the LEAS.

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Limitations
There are limitations to this study. Foremost, it is based on a cross-sectional analysis which limits the possibility of inferringcausal mechanisms[...]

although patients with CFS performed worse on the LEAS, they also took significantly more time to complete it, indicating slower information processing speed. Cognitive capacity was not measured in this study, and therefore could not be controlled for; however, one meta-analysis has indicated that patients with CFS have memory and attentional deficits (Cockshell & Mathias, 2010). These cognitive deficits might hinder patients with CFS fully using their emotional awareness capacity.

However, a recent review indicates that patients with ES have similar cognitive deficits as patients with CFS (Grossi et al., 2015). Given that patients with ES did not perform any differently from HCs in the LEAS, a more reasonable interpretation is that patients with CFS have more difficulties with emotional processing, thus making them struggle for a longer time to find answers for the LEAS.

Thanks for providing all this info, mango. I haven't been able to access the full paper.

I'm pleased to see them recognising that CFS is an organic illness. But I'm still suspicious about why they want to do such a study.

And I notice they quote a Chalder claim of curing 18% of CFS patients with CBT. In the light of the PACE results reanalysis this looks distinctly dodgy.

I don't know why I'm bothering with this really, especially as it's 2.15am here and I should be asleep. Since sleep is eluding me, I fancied some human interaction and this was the best i could find! Thanks for your company, mango!!!!

Clinical implications
Alexithymia has been associated with poor outcomes in psychodynamic therapy and supportive therapy [...] Moreover, difficulties in emotional awareness capacity have been shown to be a strong moderator of treatment effectiveness in both CBT and psychodynamic psychotherapy (Beutel, Scheurich, Knebel et al., 2013).

Thank *you* for your company, trishrhymes! It's in the middle of the night here too, but I'm still wide awake because I slept all day (my body clock is totally out of whack because I'm in a crash at the moment...).

Yes, it's nice to see them recognising CFS as an organic illness, but sadly those words are kind of worthless unless they are also reflected in their actions etc...

Many of Ljungar's patients believe that she has a fully biomedical approach to ME/CFS (despite her history of BPS research into ME/CFS etc), and are happy to take part in her studies etc, so it feels very important to me to try and pull the curtains back a bit and show them what's really going on; what Ljungar is actually focusing on, despite what she claims when talking to her patients...

Interesting background information mango. What treatment does she use?

The fact that she's quoting White and Chalder's success claims without questioning their validity for an organic condition shows you're right to doubt her.

Would she believe CBT can cure people with any other organic illness, I wonder. It would be interesting to ask her whether she thinks CBT, with or without her added emotion training would cure MS or Parkinson's disease.

Would she believe CBT can cure people with any other organic illness, I wonder. It would be interesting to ask her whether she thinks CBT, with or without her added emotion training would cure MS or Parkinson's disease.

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Very good questions... I'd be very interested in getting to know what she truly believes,...

I don't know what treatments she is currently using. I've seen extremely few mentions about treatments so far (in the Swedish ME/CFS discussion groups), it's possible that most of her patients are still going through the diagnostic process with lots of different tests and interviews etc.

Ljungar is currently planning a ME/CFS study on Chlamydia Pneumoniaue (TWAR), and another one about potential biomarkers in saliva and blood plasma (I haven't gotten around to reading the details about them yet). Also, there's another Swedish researcher with BPS beliefs, Gunnar Olsson, currently doing what is presented as "biomedical" research into ME/CFS,... however, reading the details of his study registration application it's quite clear that it's actually about CBT/GET

I just wish the BPS people would leave the biomedical research to the genuinely biomedical researchers. I suspect these studies might only muddy the waters even further, and once again hog all of what very little research funding there is...